Survival of Arteriovenous Fistula for Dialysis at Different Centers in the North of England

Background

Renal failure patients rely on their vascular access for hemodialysis. Surgery for construction of arteriovenous fistulae is provided by a range of specialists. The aim of this review was to assess the survival of arteriovenous fistulae for hemodialysis patients in different centers of Northern England.

Methods

Data was collected on 473 hemodialysis patients in the North of England. Risk factors for failure were determined for each patient (age, sex, diabetes), together with their current mode of dialysis and history of surgical access procedures. This was expressed against their duration of dialysis. The dialysis units were then compared for fistula survival using the Kaplan Meier method.

Results

68.3% (323) patients were dialysed through via arteriovenous fistulae and 31.7% (150) via neck line. Overall fistula survival rates were 85.1% at 1 year, 82.5% at 2 years and 72.7% at 3 years. The best 1 year survival was 91.6% and worst 76.1%. These were 74.4% and 53.1% at 5 years and 74.4% and 29.5% at 10 years; these differences were highly statistically significant (p=0.0033).

Conclusion

Though graft survival is affected by many things, surgical training in access surgery is not mandatory and a review of surgical practice is urgently needed.

Evaluation of the Quebec Healthy Enterprise Standard: Effect on Adverse Psychosocial Work Factors and Psychological Distress

Adverse psychosocial work factors are recognized as a significant source of psychological distress, resulting in a considerable socioeconomic burden. The impact of occupational health standards that aim to reduce these adverse work factors, such as the Quebec Healthy Enterprise Standard (QHES), is of great interest for public health. The aim of this study was to evaluate, for the first time, the effect of QHES interventions targeting adverse psychosocial work factors on the prevalence of these factors and of psychological distress among ten Quebec organizations. These outcomes were assessed by questionnaire using validated instruments before (T1, n = 2849) and 2-3 years following (T2, n = 2560) QHES implementation. Beneficial effects of interventions were observed for two adverse psychosocial work factors: low rewards (ratio of prevalence ratios (PRs) = 0.77, 95% CI = 0.66-0.91) and low social support at work (ratio of PRs = 0.89, 95% CI = 0.77-1.03). Moreover, beneficial effects of interventions were also observed on the prevalence of high psychological distress (ratio of PRs = 0.86, 95% CI = 0.75-0.998). Psychosocial interventions implemented in the context of this standard improved the psychosocial work environment and had beneficial effects on workers' mental health.

INITIATION OF PATIENTS ONTO LONG-ACTING SOMATOSTATIN ANALOGUE THERAPY FOR NEUROENDOCRINE TUMORS: A SINGLE-CENTER REVIEW OF PRACTICE

OBJECTIVE

Neuroendocrine tumors (NETs) are being seen increasingly frequently, and recent data show that long-acting somatostatin analogues have become a major initial treatment, regardless of whether the tumors are functioning or not. However, test dosing with subcutaneous (sc) octreotide is usually advised to assess longer-term tolerability, although this advice is mainly based on results with functioning tumors. The aim of the study was to assess the value of an initiating test dose of sc octreotide on the prediction of subsequent adverse events after treatment with the long-acting analogue.

METHODS

In a single, large Centre of Excellence for NETs, a first cohort of patients (n = 24) was admitted overnight after an sc injection of octreotide, and then administered the analogue; a subsequent group (n = 53) had the test dose performed on an outpatient basis. Side effects were recorded after the test dose and subsequent treatment with the long-acting analogue.

RESULTS

The test dose injection was of little value in predicting adverse events following the long-acting somatostatin analogue.

CONCLUSION

Unless there are serious symptoms associated with a functioning NET, it is unnecessary to carry out a test dose; a change to this procedure will improve resource allocation and should enhance early initiation onto maintenance therapy.

ABBREVIATIONS

CLARINET = Controlled study of lanreotide antiproliferative response in neuroendocrine tumors LAR = long-acting repeatable NET = neuroendocrine tumor PROMID = Placebo-controlled, double-blind, prospective, randomized study on the effect of octreotide LAR in the control of tumor growth in patients with meta-static neuroendocrine midgut tumors.

The burden of neutropenic sepsis in patients with advanced non-small cell lung cancer treated with single-agent docetaxel: A retrospective study

OBJECTIVES

To describe rates of confirmed and suspected neutropenic sepsis (NS) and associated hospital resource utilisation in patients with non-small cell lung cancer (NSCLC) treated with docetaxel monotherapy following relapse after ≥1 line of chemotherapy in routine UK clinical practice.

MATERIALS AND METHODS

A multi-centre, retrospective, observational research study was conducted in seven centres across England and Wales. Adult patients with stage III/IV NSCLC initiated on docetaxel monotherapy between 2010 and 2016 in routine clinical practice (aged ≥18 years at initiation) following failure of first-line chemotherapy were eligible. Data were collected from hospital medical records between May 2016 and July 2016, on all episodes of confirmed or suspected NS related to docetaxel monotherapy, including patient characteristics. Episodes of confirmed NS were defined as documented absolute neutrophil count <1.0×10⁹/L, plus temperature >38°C or other signs/symptoms of sepsis, otherwise episodes were classified as suspected NS.

RESULTS

121 patients were included (median age 65.5 years; 57.9% male; median 4.0 cycles of docetaxel; 19.8% treated with prophylactic granulocyte-colony stimulating factor). Episodes of confirmed or suspected NS were recorded in 21/121 (17.4%) patients (11 confirmed episodes in 11 [9.1%] patients and 11 suspected episodes in 10 [8.3%] patients). Resource utilisation data were available for 21/22 episodes; the mean length of stay for confirmed NS admissions (n=11) was 9.2 (SD: 9.2) days and for suspected NS admissions (n=10) was 4.7 (SD: 4.6) days. The most commonly prescribed treatment for NS was piperacillin/tazobactam therapy (46.5% of all documented treatments). The mean total costs of managing patients with confirmed NS (n=11) and suspected NS (n=9) were £3163 (SD: £2921) and £1790 (SD: £1585) per patient, respectively.

CONCLUSION

Rates of confirmed NS in UK clinical practice were broadly similar to those reported in clinical trials; however, the burden of suspected NS, not routinely reported elsewhere, is also substantial.

Effects of climate and fine particulate matter on hospitalizations and deaths for heart failure in elderly: A population-based cohort study

BACKGROUND

There are limited data on the effects of climate and air pollutant exposure on heart failure (HF) within taking into account individual and contextual variables.

OBJECTIVES

We measured the lag effects of temperature, relative humidity, atmospheric pressure and fine particulate matter (PM_2.5) on hospitalizations and deaths for HF in elderly diagnosed with this disease on a 10-year period in the province of Quebec, Canada.

METHODS

Our population-based cohort study included 112,793 elderly diagnosed with HF between 2001 and 2011. Time dependent Cox regression models approximated with pooled logistic regressions were used to evaluate the 3- and 7-day lag effects of daily temperature, relative humidity, atmospheric pressure and PM_2.5 exposure on HF morbidity and mortality controlling for several individual and contextual covariates.

RESULTS

Overall, 18,309 elderly were hospitalized and 4297 died for the main cause of HF. We observed an increased risk of hospitalizations and deaths for HF with a decrease in the average temperature of the 3 and 7days before the event. An increase in atmospheric pressure in the previous 7days was also associated with a higher risk of having a HF negative outcome, but no effect was observed in the 3-day lag model. No association was found with relative humidity and with PM_2.5 regardless of the lag period.

CONCLUSIONS

Lag effects of temperature and other meteorological parameters on HF events were limited but present. Nonetheless, preventive measures should be issued for elderly diagnosed with HF considering the burden and the expensive costs associated with the management of this disease.

Comparison of the impact of SFAs from cheese and butter on cardiometabolic risk factors: a randomized controlled trial

Background: Controversies persist concerning the association between intake of dietary saturated fatty acids (SFAs) and cardiovascular disease risk.Objective: We compared the impact of consuming equal amounts of SFAs from cheese and butter on cardiometabolic risk factors.Design: In a multicenter, crossover, randomized controlled trial, 92 men and women with abdominal obesity and relatively low HDL-cholesterol concentrations were assigned to sequences of 5 predetermined isoenergetic diets of 4 wk each separated by 4-wk washouts: 2 diets rich in SFAs (12.4-12.6% of calories) from either cheese or butter; a monounsaturated fatty acid (MUFA)-rich diet (SFAs: 5.8%, MUFAs: 19.6%); a polyunsaturated fatty acid (PUFA)-rich diet (SFAs: 5.8%, PUFAs: 11.5%); and a low-fat, high-carbohydrate diet (fat: 25%, SFAs: 5.8%).Results: Serum HDL-cholesterol concentrations were similar after the cheese and butter diets but were significantly higher than after the carbohydrate diet (+3.8% and +4.7%, respectively; P < 0.05 for both). LDL-cholesterol concentrations after the cheese diet were lower than after the butter diet (-3.3%, P < 0.05) but were higher than after the carbohydrate (+2.6%), MUFA (+5.3%), and PUFA (+12.3%) diets (P < 0.05 for all). LDL-cholesterol concentrations after the butter diet also increased significantly (from +6.1% to +16.2%, P < 0.05) compared with the carbohydrate, MUFA, and PUFA diets. The LDL-cholesterol response to treatment was significantly modified by baseline values (P-interaction = 0.02), with the increase in LDL cholesterol being significantly greater with butter than with cheese only among individuals with high baseline LDL-cholesterol concentrations. There was no significant difference between all diets on inflammation markers, blood pressure, and insulin-glucose homeostasis.Conclusions: The results of our study suggest that the consumption of SFAs from cheese and butter has similar effects on HDL cholesterol but differentially modifies LDL-cholesterol concentrations compared with the effects of carbohydrates, MUFAs, and PUFAs, particularly in individuals with high LDL cholesterol. In contrast, SFAs from either cheese or butter have no significant effects on several other nonlipid cardiometabolic risk factors. This trial was registered at clinicaltrials.gov as NCT02106208.

Chronic exposure to adverse psychosocial work factors and high psychological distress among white-collar workers: A 5-year prospective study

OBJECTIVES

Prospective studies which evaluated whether the effects of chronic exposure to psychosocial work factors on mental health persisted over time are scarce. For the first time, this study evaluated: 1) the effect of chronic exposure to effort-reward imbalance over 5years on the prevalence of high psychological distress among men and women, and 2) the persistence of this effect over time.

METHODS

Overall, 1747 white-collar workers from three public organizations participated in a prospective study. Psychological distress and effort-reward imbalance were measured using validated questionnaires at baseline, and at 3- and 5-year follow-ups. Prevalence ratios (PRs) of high psychological distress were estimated using log-binomial regression according to baseline and repeated exposure.

RESULTS

Compared to unexposed workers, those with repeated exposure to effort-reward imbalance had a higher prevalence of high psychological distress. Workers exposed only at some time-points also had a higher prevalence. The deleterious effect of repeated exposure observed at the 3-year follow-up persisted at the 5-year follow-up among women (PR=2.48 95% confidence interval (CI) 1.97-3.11) and men (PR=1.91 95% CI 1.20-3.04). These effects were greater than those found using a single baseline measurement.

CONCLUSION

The current study supported a deleterious effect of repeated exposure to effort-reward imbalance on psychological distress, and a lack of adaptation to these effects over time among men and women. Since psychological distress may later lead to severe mental problems, current results highlight the need to consider exposure to these adverse work factors in primary and secondary preventions aimed at reducing mental health problems at work.

Clinical applicability and cost of a 46-gene panel for genomic analysis of solid tumours: Retrospective validation and prospective audit in the UK National Health Service

BACKGROUND

Single gene tests to predict whether cancers respond to specific targeted therapies are performed increasingly often. Advances in sequencing technology, collectively referred to as next generation sequencing (NGS), mean the entire cancer genome or parts of it can now be sequenced at speed with increased depth and sensitivity. However, translation of NGS into routine cancer care has been slow. Healthcare stakeholders are unclear about the clinical utility of NGS and are concerned it could be an expensive addition to cancer diagnostics, rather than an affordable alternative to single gene testing.

METHODS AND FINDINGS

We validated a 46-gene hotspot cancer panel assay allowing multiple gene testing from small diagnostic biopsies. From 1 January 2013 to 31 December 2013, solid tumour samples (including non-small-cell lung carcinoma [NSCLC], colorectal carcinoma, and melanoma) were sequenced in the context of the UK National Health Service from 351 consecutively submitted prospective cases for which treating clinicians thought the patient had potential to benefit from more extensive genetic analysis. Following histological assessment, tumour-rich regions of formalin-fixed paraffin-embedded (FFPE) sections underwent macrodissection, DNA extraction, NGS, and analysis using a pipeline centred on Torrent Suite software. With a median turnaround time of seven working days, an integrated clinical report was produced indicating the variants detected, including those with potential diagnostic, prognostic, therapeutic, or clinical trial entry implications. Accompanying phenotypic data were collected, and a detailed cost analysis of the panel compared with single gene testing was undertaken to assess affordability for routine patient care. Panel sequencing was successful for 97% (342/351) of tumour samples in the prospective cohort and showed 100% concordance with known mutations (detected using cobas assays). At least one mutation was identified in 87% (296/342) of tumours. A locally actionable mutation (i.e., available targeted treatment or clinical trial) was identified in 122/351 patients (35%). Forty patients received targeted treatment, in 22/40 (55%) cases solely due to use of the panel. Examination of published data on the potential efficacy of targeted therapies showed theoretically actionable mutations (i.e., mutations for which targeted treatment was potentially appropriate) in 66% (71/107) and 39% (41/105) of melanoma and NSCLC patients, respectively. At a cost of £339 (US$449) per patient, the panel was less expensive locally than performing more than two or three single gene tests. Study limitations include the use of FFPE samples, which do not always provide high-quality DNA, and the use of "real world" data: submission of cases for sequencing did not always follow clinical guidelines, meaning that when mutations were detected, patients were not always eligible for targeted treatments on clinical grounds.

CONCLUSIONS

This study demonstrates that more extensive tumour sequencing can identify mutations that could improve clinical decision-making in routine cancer care, potentially improving patient outcomes, at an affordable level for healthcare providers.

A graphical perspective of marginal structural models: An application for the estimation of the effect of physical activity on blood pressure

Estimating causal effects requires important prior subject-matter knowledge and, sometimes, sophisticated statistical tools. The latter is especially true when targeting the causal effect of a time-varying exposure in a longitudinal study. Marginal structural models are a relatively new class of causal models that effectively deal with the estimation of the effects of time-varying exposures. Marginal structural models have traditionally been embedded in the counterfactual framework to causal inference. In this paper, we use the causal graph framework to enhance the implementation of marginal structural models. We illustrate our approach using data from a prospective cohort study, the Honolulu Heart Program. These data consist of 8006 men at baseline. To illustrate our approach, we focused on the estimation of the causal effect of physical activity on blood pressure, which were measured at three time points. First, a causal graph is built to encompass prior knowledge. This graph is then validated and improved utilizing structural equation models. We estimated the aforementioned causal effect using marginal structural models for repeated measures and guided the implementation of the models with the causal graph. By employing the causal graph framework, we also show the validity of fitting conditional marginal structural models for repeated measures in the context implied by our data.

30-day mortality after systemic anticancer treatment for breast and lung cancer in England: a population-based, observational study

BACKGROUND

30-day mortality might be a useful indicator of avoidable harm to patients from systemic anticancer treatments, but data for this indicator are limited. The Systemic Anti-Cancer Therapy (SACT) dataset collated by Public Health England allows the assessment of factors affecting 30-day mortality in a national patient population. The aim of this first study based on the SACT dataset was to establish national 30-day mortality benchmarks for breast and lung cancer patients receiving SACT in England, and to start to identify where patient care could be improved.

METHODS

In this population-based study, we included all women with breast cancer and all men and women with lung cancer residing in England, who were 24 years or older and who started a cycle of SACT in 2014 irrespective of the number of previous treatment cycles or programmes, and irrespective of their position within the disease trajectory. We calculated 30-day mortality after the most recent cycle of SACT for those patients. We did logistic regression analyses, adjusting for relevant factors, to examine whether patient, tumour, or treatment-related factors were associated with the risk of 30-day mortality. For each cancer type and intent, we calculated 30-day mortality rates and patient volume at the hospital trust level, and contrasted these in a funnel plot.

FINDINGS

Between Jan 1, and Dec, 31, 2014, we included 23 228 patients with breast cancer and 9634 patients with non-small cell lung cancer (NSCLC) in our regression and trust-level analyses. 30-day mortality increased with age for both patients with breast cancer and patients with NSCLC treated with curative intent, and decreased with age for patients receiving palliative SACT (breast curative: odds ratio [OR] 1·085, 99% CI 1·040-1·132; p<0·0001; NSCLC curative: 1·045, 1·013-1·079; p=0·00033; breast palliative: 0·987, 0·977-0·996; p=0·00034; NSCLC palliative: 0·987, 0·976-0·998; p=0·0015). 30-day mortality was also significantly higher for patients receiving their first reported curative or palliative SACT versus those who received SACT previously (breast palliative: OR 2·326 99% CI 1·634-3·312; p<0·0001; NSCLC curative: 3·371, 1·554-7·316; p<0·0001; NSCLC palliative: 2·667, 2·109-3·373; p<0·0001), and for patients with worse general wellbeing (performance status 2-4) versus those who were generally well (breast curative: 6·057, 1·333-27·513; p=0·0021; breast palliative: 6·241, 4·180-9·319; p<0·0001; NSCLC palliative: 3·384, 2·276-5·032; p<0·0001). We identified trusts with mortality rates in excess of the 95% control limits; this included seven for curative breast cancer, four for palliative breast cancer, five for curative NSCLC, and seven for palliative NSCLC.

INTERPRETATION

Our findings show that several factors affect the risk of early mortality of breast and lung cancer patients in England and that some groups are at a substantially increased risk of 30-day mortality. The identification of hospitals with significantly higher 30-day mortality rates should promote review of clinical decision making in these hospitals. Furthermore, our results highlight the importance of collecting routine data beyond clinical trials to better understand the factors placing patients at higher risk of 30-day mortality, and ultimately improve clinical decision making. Our insights into the factors affecting risk of 30-day mortality will help treating clinicians and their patients predict the balance of harms and benefits associated with SACT.

FUNDING

Public Health England.

A randomized, crossover, head-to-head comparison of eicosapentaenoic acid and docosahexaenoic acid supplementation to reduce inflammation markers in men and women: the Comparing EPA to DHA (ComparED) Study

BACKGROUND

To date, most studies on the anti-inflammatory effects of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in humans have used a mixture of the 2 fatty acids in various forms and proportions.

OBJECTIVES

We compared the effects of EPA supplementation with those of DHA supplementation (re-esterified triacylglycerol; 90% pure) on inflammation markers (primary outcome) and blood lipids (secondary outcome) in men and women at risk of cardiovascular disease.

DESIGN

In a double-blind, randomized, crossover, controlled study, healthy men (n = 48) and women (n = 106) with abdominal obesity and low-grade systemic inflammation consumed 3 g/d of the following supplements for periods of 10 wk: 1) EPA (2.7 g/d), 2) DHA (2.7 g/d), and 3) corn oil as a control with each supplementation separated by a 9-wk washout period. Primary analyses assessed the difference in cardiometabolic outcomes between EPA and DHA.

RESULTS

Supplementation with DHA compared with supplementation with EPA led to a greater reduction in interleukin-18 (IL-18) (-7.0% ± 2.8% compared with -0.5% ± 3.0%, respectively; P = 0.01) and a greater increase in adiponectin (3.1% ± 1.6% compared with -1.2% ± 1.7%, respectively; P < 0.001). Between DHA and EPA, changes in CRP (-7.9% ± 5.0% compared with -1.8% ± 6.5%, respectively; P = 0.25), IL-6 (-12.0% ± 7.0% compared with -13.4% ± 7.0%, respectively; P = 0.86), and tumor necrosis factor-α (-14.8% ± 5.1% compared with -7.6% ± 10.2%, respectively; P = 0.63) were NS. DHA compared with EPA led to more pronounced reductions in triglycerides (-13.3% ± 2.3% compared with -11.9% ± 2.2%, respectively; P = 0.005) and the cholesterol:HDL-cholesterol ratio (-2.5% ± 1.3% compared with 0.3% ± 1.1%, respectively; P = 0.006) and greater increases in HDL cholesterol (7.6% ± 1.4% compared with -0.7% ± 1.1%, respectively; P < 0.0001) and LDL cholesterol (6.9% ± 1.8% compared with 2.2% ± 1.6%, respectively; P = 0.04). The increase in LDL-cholesterol concentrations for DHA compared with EPA was significant in men but not in women (P-treatment × sex interaction = 0.046).

CONCLUSIONS

DHA is more effective than EPA in modulating specific markers of inflammation as well as blood lipids. Additional studies are needed to determine the effect of a long-term DHA supplementation per se on cardiovascular disease risk. This trial was registered at clinicaltrials.gov as NCT01810003.

A case of a living-related kidney transplantation after ex-vivo repair of the donor renal artery aneurysm

BACKGROUND

Kidney transplantation is the definite surgical treatment for end-stage renal disease. Shortage of organs and the increasing number of patients with end-stage renal disease has led to an expansion of the selection criteria promoting the use of organs from marginal donors. Use of kidneys with renal artery aneurysm (RAA) is one such example. Description of the case: We report a case of living-related kidney transplantation from a 46-year-old female donor with unilateral RAA to her 68-year-old father. The pre-operative donor's assessment with a computed tomography angiogram revealed a saccular aneurysm of the left renal artery. The transplant team proceeded to the left nephrectomy, surgical ex vivo repair of the aneurysm and transplantation of this kidney to the recipient, with the total ischemic time of 130 minutes. At revascularization, there was no anastomotic leak with good perfusion of the organ and normal postoperative kidney function.

CONCLUSION

RAA is a rare renal anatomical abnormality with unproven clinical significance. Advanced microvascular surgical techniques can be used to repair the aneurysm with subsequent successful use for transplantation. Hippokratia 2016, 20(1): 90-92.

Dual kidney transplantation: a single-center experience

BACKGROUND

Dual kidney transplantation (DKT) is an alternate approach to use marginal kidneys not suitable to be allocated for single kidney transplant. This retrospective study reviewed the short- and long-term outcomes regarding graft and patient survivals over a 9-year period at a single center.

METHODS

From 2005 to 2013, 33 DKTs were performed in our unit, where allocation was guided by clinical parameters mainly. The mean ages for recipients and donors were 58.6 ± 12.5 and 54.8 ± 13.6 years, respectively. Cold ischemia time was 21.4 ± 4 hours, and mean HLA mismatch for HLA-A, HLA-B, and HLA-DR was 3.06 ± 1.07. Immunosuppression regime was tacrolimus based.

RESULTS

Median follow-up time of 56 months showed patient and death-censored graft survivals at 1, 3, and 5 years to be 90% and 84%, 90% and 81%, and 84% and 81%, respectively. The rate of delayed graft function was 46.9% (n = 15), the rate of primary graft function was 46.9% (n = 15), the rate of and primary graft nonfunction was 6.2% (n = 2). Nineteen patients (59.4%) required biopsy: 12 of them showed acute tubular necrosis and 7 had rejection (1 needed graft removal, 4 were treated successfully with steroid and/or antithymocyte globulin, and 2 did not require treatment).

CONCLUSIONS

Outcomes of DKT in our center were satisfactory and similar to those of other transplant centers regarding patient and graft survivals.

A cautionary note concerning the use of stabilized weights in marginal structural models

Marginal structural models are commonly used to estimate the causal effect of a time-varying treatment in presence of time-dependent confounding. When fitting an MSM to data, the analyst must specify both the structural model for the outcome and the treatment models for the inverse-probability-of-treatment weights. The use of stabilized weights is recommended because they are generally less variable than the standard weights. In this paper, we are concerned with the use of the common stabilized weights when the structural model is specified to only consider partial treatment history, such as the current or most recent treatments. We present various examples of settings where these stabilized weights yield biased inferences while the standard weights do not. These issues are first investigated on the basis of simulated data and subsequently exemplified using data from the Honolulu Heart Program. Unlike common stabilized weights, we find that basic stabilized weights offer some protection against bias in structural models designed to estimate current or most recent treatment effects.